outbreaks and safe injection practices in...
TRANSCRIPT
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OUTBREAKS AND SAFE INJECTION PRACTICES IN OUTPATIENT SETTINGS
Statewide Program for Infection Control and Epidemiology (SPICE)
UNC School of Medicine
Module D
OBJECTIVES
1. Discuss the consequences of unsafe injection practices
2. Describe outbreaks
3. Discuss safe injection best practices
4. Describe One and Only Campaign
UNSAFE INJECTION PRACTICESCONSEQUENCES
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VIRAL HEPATITIS OUTBREAKS REPORTED TO CDC 2008‐2017
Healthcare Setting Breach in Infection Prevention
Long Term Care Assisted blood glucose monitoring (ABGM)
Pain Management Clinic Syringe reuse and reuse of single‐dose vials
Outpatient Oncology Reuse of single‐dose vial and lack of asepsis while preparing medication
Hemodialysis Lack of hand hygiene, environmental cleaning/ disinfection and asepsis
Other Outpatient Settings Syringe reuse; reuse of single dose vial; Drug diversion; ABGM;
NC VIRAL HEPATITIS OUTBREAKS REPORTED TO CDC 2001‐2012
Healthcare Setting Breach in Infection Prevention
Long Term Care Assisted blood glucose monitoring (ABGM)
Exposed ‐ 504 Infections ‐ 31 Deaths ‐ 6
Cardiology Clinic Syringe reuse and contaminating multi‐dose vials
Exposed ‐ 1200 Infections ‐ 5
KNOWLEDGE CHECK
Which of the following statements is correct?
1. CDC reports that most outbreaks occur in the hospital
2. Outbreaks of HIV are the most common type of outbreak
3. CDC reports that most outbreaks occur in non‐hospital settings and are associated with unsafe injection practices and assisted blood glucose monitoring
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WHY DO OUTBREAKS HAPPEN
1.Syringe re-use, directly or indirectly
2. Inappropriate use of single dose or single use vials
3.Failure to use aseptic technique (contamination of injection equipment)
4.Unsafe diabetes care/ assisted blood glucose monitoring (ABGM)
THE BIG FOUR
SYRINGE RE‐USE
• Most common cause of outbreaks in the outpatient setting is inappropriate use of syringes:
• Direct reuse:
• Using the same syringe to administer medication to more than one patient, even if the needle is changed or the injection was administered through an intervening length of tubing
• Indirect reuse or “double dipping”:
• Accessing a medication vial or bag with a syringe that has already been used to administer medication to a patient, then reusing the contents from the vial or bag for another patient
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SYRINGE RE‐USEVideo Clip: Start the video by clicking on the image below.
ENDOSCOPY CENTER, NEVADA (2008)
• 9 clinic‐associated hepatitis C virus cases
• 106 possible clinic‐associated cases
• 63,000 potential exposures
• $16–21 million total cost
DANGEROUS MISPERCEPTIONS
1. Changing the needle makes a syringe safe for reuse.
2. Syringes can be reused as long as an injection is administered through an intervening length of IV tubing.
3. If you don't see blood in the IV tubing or syringe, it means that those supplies are safe for reuse.
Once they are used, both the needle and syringe are contaminated and must be discarded!
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INAPPROPRIATE USE OF SINGLE‐DOSE/SINGLE‐USE VIALS
• Vials labeled as single use:
• NO PRESERVATIVE
• Can be accessed one time only and for one patient onlyand remaining contents must be discarded
• CDC is aware of at least 19 outbreaks involving single dose vial use
• All occurred in outpatient setting with almost half in pain remediation clinics
SINGLE DOSE VIALS:CDC POSITION STATEMENT, 2012
• Vials labeled by the manufacturer as “single dose” or “single use” should only be used for a single patient.
• Ongoing outbreaks provide ample evidence that inappropriate use of single‐dose/single‐use vials causes patient harm.
• Leftover parenteral medications should never be pooled for later administration
• In times of critical need, contents from unopened single dose vials can be repackaged for multiple patients in accordance with standards in United States Pharmacopeia General Chapter ‹797›
www.cdc.gov/injectionsafety/CDCposition-SingleUseVial.html
WHEN FAILURE TO USE ASEPTIC TECHNIQUEHAPPENS!
• Two women diagnosed with HBV infection, receiving chemotherapy at the same physician practice
• Multidisciplinary team investigation
• Office closed, physician license suspended
• 2,700 patients notified
• 29 outbreak‐associated cases of HBV
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NEW JERSEY – ONCOLOGY OFFICE
IV bags with stoppers removed
IV bags used as sources of fluid to flush catheters for multiple patients
NEW JERSEY – ONCOLOGY OFFICE
Medication prepared in hood in patient treatment area
Blood drawing
preparation
Blood drawing equipment in area of medication preparation
Medication prepared in advance
Uncapped syringes for flushing IVs unwrapped and prefilled in advance
NEW JERSEY – ONCOLOGY OFFICE
Blood contamination
Reused Vacutainer holders in contact with gauze
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KNOWLEDGE CHECK
• Which of the following statements is false?
1. Syringes can be used on more than one patient if the needle is changed.
2. Single dose vials can be used more than one time if it has not been contaminated
3. Blood glucose meters do not have contact with patients and do not need to be cleaned
4. If there is no visible blood the syringe is safe to reuse.
5. All of the above
UNSAFE DIABETES CARE
Use of fingerstick devices or insulin pens on multiple
persons
Sharing of blood glucose meters without cleaning and disinfection between uses
Failure to perform hand hygiene or change gloves
between procedures
Patel et al. ICHE 2009; 30:209-14,Thompson et al. JAGS 2010, MMWR 2005; 54:220-3
SAFE INJECTIONS: BEST PRACTICES
Syringe reuse (direct and indirect)
• Never administer medications from the same syringe to multiple patients
• Do not reuse a syringe to enter a medication vial or solution
• Limit the use of multi‐dose vials and dedicate them to a single patient whenever possible
Misuse of single‐dose/single‐use vials
• Do not administer medications from a single dose vial or IV solution bag to more than one patient, more than one time
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SAFE INJECTIONS: BEST PRACTICES
Failure to use aseptic technique
• Use aseptic technique when preparing or administering medications
Unsafe diabetes care
• Use insulin pens and lancing devices for only one patient
• Dedicate glucometers to a single patient. If they MUST be shared, clean and disinfect after each use
MOST OUTBREAKS ARE NEVER DETECTED
Asymptomatic infection
Under‐reporting of cases
Under‐recognition of healthcare as risk
Barriers to investigation,
resource constraints
Long incubation period;
difficult to identify single healthcare
exposure
SURVEY OF PHYSICIAN AND NURSE PRACTICES AROUND INJECTION SAFETY
• 370 Physicians
• 320 Nurses
• Eight States Included
• NC, NY, NJ, Nevada, Colorado, Tennessee, Wisconsin, Montana
• Types of healthcare settings:
• Acute care, long term care, outpatient settings
https://www.sciencedirect.com/science/article/pii/S0196655317306806?via%3Dihub
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SURVEY FINDINGS
TopicIs Acceptable Practice
Physician Response
Nurse Response
Reuse of syringe for > one patient
12.4% 3.4%
Reentering a vial with a used needle/syringe
12.7% 6.7%
Using SDVs for multiple patients
34% 16.9%
Using source bags as diluent for multiple patients
28.9% 13.1%
KNOWLEDGE CHECK
True or False
Because there have been so many outbreaks, ALL healthcare providers do the right thing every time with safe injection practices.
True False
BEST PRACTICE
• Designate someone to provide ongoing oversight
• Develop written infection control policies
• Provide training
• Conduct quality assurance assessments
Speak Up!
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ONE AND ONLY CAMPAIGN
• Print Materials• Audio & Visual• Social Media• Toolkits
CAMPAIGN RESOURCES
WWW.ONEANDOHTTP://WWW.ONEANDONLYCAMPAIGN.ORG/PARTNER/NORTH-CAROLINALYCAMPAIGN.ORG
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QUESTIONS?